Optimising Hand Surgery during COVID-19 Pandemic.

Background: With the emergence of the COVID-19 pandemic, most health-care personnel and resources are redirected to prioritize care for seriously-ill COVID patients. This situation may poorly impact our capacity to care for critically injured patients. We need to devise a strategy to provide rational and essential care to hand trauma victims whilst the access to theatres and anaesthetic support is limited. Our center is a level 1 trauma center, where the pandemic preparedness required reorganization of the trauma services. We aim to summarise the clinical profile and management of these patients and highlight, how we modified our practice to optimize their care. Methods: This is a single-centre retrospective observational study of all patients with hand injuries visiting the Department of Plastic Surgery from 22nd March to 31st May 2020. Patient characteristics, management details, and outcomes were analysed. Results: A total of 102 hand injuries were encountered. Five patients were COVID-19 positive. The mean age was 28.9 ± 14.8 years and eighty-two (80.4%) were males. Thirty-one injuries involved fractures/dislocations, of which 23 (74.2%) were managed non-operatively. Seventy-five (73.5%) patients underwent wound wash or procedure under local anaesthetic and were discharged as soon as they were comfortable. Seventeen cases performed under brachial-plexus block, were discharged within 24 hours except four cases of finger replantation/ revascularisation and one flap cover which were discharged after monitoring for four days. At mean follow-up of 54.4 ± 21.8 days, the rates of early complication and loss to follow-up were 6.9% and 12.7% respectively. Conclusions: Essential trauma care needs to continue keeping in mind, rational use of resources while ensuring safety of the patients and health-care professionals. We need to be flexible and dynamic in our approach, by utilising teleconsultation, non-operative management, and regional anaesthesia wherever feasible.

Using Local Anesthesia for Inguinal Hernia Repair Reduces Complications in Older Patients.

BACKGROUND: Inguinal hernia repair is the most common general surgery operation in the United States. Nearly 80% of inguinal hernia operations are performed under general anesthesia versus 15%-20% using local anesthesia, despite the absence of evidence for the superiority of the former. Although patients aged 65 y and older are expected to benefit from avoiding general anesthesia, this presumed benefit has not been adequately studied. We hypothesized that the benefits of local over general anesthesia for inguinal hernia repair would increase with age. MATERIALS AND METHODS: We analyzed 87,794 patients in the American College of Surgeons National Surgical Quality Improvement Project who had elective inguinal hernia repair under local or general anesthesia from 2014 to 2018, and we used propensity scores to adjust for known confounding. We compared postoperative complications, 30-day readmissions, and operative time for patients aged <55 y, 55-64 y, 65-74 y, and ≥75 y. RESULTS: Using local rather than general anesthesia was associated with a 0.6% reduction in postoperative complications in patients aged 75+ y (95% CI -0.11 to -1.13) but not in younger patients. Local anesthesia was associated with faster operative time (2.5 min - 4.7 min) in patients <75 y but not in patients aged 75+ y. Readmissions did not differ by anesthesia modality in any age group. Projected national cost savings for greater use of local anesthesia ranged from $9 million to $45 million annually. CONCLUSIONS: Surgeons should strongly consider using local anesthesia for inguinal hernia repair in older patients and in younger patients because it is associated with significantly reduced complications and substantial cost savings.

A Cross-Sectional Analysis of Community Water Fluoridation and Prevalence of Pediatric Dental Surgery Among Medicaid Enrollees.

Importance: Dental surgery under general anesthesia (DGA) is an ineffective, costly treatment for caries. Interventions to reduce the need for DGA are challenging because children's parents may not seek care until surgery is required. Community water fluoridation (CWF) effectively prevents early childhood caries, but its effectiveness in reducing severe early childhood caries is unknown. Objective: To determine whether access to CWF is associated with the prevalence of DGA. Design, Setting, and Participants: This is a cross-sectional analysis of Medicaid claims data from 2011 to 2012. Deidentified data were derived from Medicaid claims and enrollee files for Massachusetts, Texas, Connecticut, Illinois, and Florida for children aged 9 years and younger enrolled in either a fee-for-service or managed care plan through their state's Medicaid program. Linear regression models tested for associations between CWF and covariates. Multivariable linear regression models tested for associations between CWF and outcomes. Regression models included clustered SEs at the county level. Data analysis was performed from December 2018 to March 2020. Exposures: Access to CWF was determined by estimating the proportion of a county's total population that had access to a fluoridated public water system. Main Outcomes and Measures: The main outcome was county-level DGA prevalence. Other outcomes were caries-related visit prevalence and patient quality indicators (asthma and diabetes). Covariates included county-level demographic, socioeconomic, and dental practitioner variables. Results: A total of 436 counties within 5 states per year (872 county-year observations), were included in the analysis. Adjusted analysis revealed that a 10% increase in the proportion of county's population access to CWF was associated with lower caries-related visit prevalence (-0.45 percentage points; 95% CI, -0.59 to -0.31 percentage points; P < .001). Increasing CWF access in 10% increments was associated with decreased DGA prevalence in unadjusted analysis (-0.39 percentage points; 95% CI, -0.67 to -0.12 percentage points; P = .006) but not in adjusted analysis (-0.23 percentage points; 95% CI, -0.49 to 0.02 percentage points; P = .07). Increasing the proportion of county's access to CWF by 10% was not associated with the prevalence of asthma-related exacerbations (-0.02 percentage points; 95% CI, -0.10 to 0.05 percentage points; P = .53) or diabetes-related exacerbations (-0.0003 percentage points; 95% CI, -0.0014 to 0.0009 percentage points; P = .66). Conclusions and Relevance: This study extends our understanding of CWF's benefits for children's oral health. Specifically, these findings suggest that increasing a population's access to CWF's is associated with decreased caries-related visits and may also be associated with use of dental surgical services within high-risk populations.

Is there disparity between regions and facilities in surgical resident training in Japan? Insights from a national survey.

PURPOSE: This study sought to assess the disparity between regions and facilities in surgical resident training in Japan via a national level needs-assessment. METHODS: A survey was sent to all 909 graduating residents of 2016. Residents trained in the six prefectures with a population of 7 million or more were included in the large prefecture (LP) group. Residents trained in the other 41 prefectures were included in the small prefecture (SP) group. Each group was further divided into a university hospital (UH) group and a non-university hospital (NUH) group. RESULTS: The response rate was 56.3% (n = 512). Excluding nine residents who did not report their prefectures and facilities, surveys from 503 residents were analyzed. The UH group received significantly more years of training. In the SP and UH groups, there were significantly fewer residents who had performed 150 procedures or more under general anesthesia in comparison to the LP and NUH groups, respectively. Self-assessed competencies for several procedures were significantly lower in the SP and UH groups. CONCLUSION: Disparity in surgical resident training was found between regions and facilities in Japan. The surgical residency curriculum in Japan could be improved to address this problem.

Comparison of peribulbar block and general anaesthesia in mechanical vitrectomy: a prospective observational study. / Comparación de bloqueo peribulbar y anestesia general en vitrectomía mecánica: estudio observacional prospectivo.

INTRODUCTION: Vitrectomy surgery is a common procedure for the treatment of several types of ophthalmologic conditions. It can be performed under regional anaesthesia with peribulbar block (PB) or general anaesthesia (GA). There are no evidence-based recommendations on the optimal anaesthesia strategy for this procedure. The aim of this study was to compare the advantages of PB and GA for vitrectomy surgery. MATERIALS AND METHODS: A prospective observational study was conducted on adults submitted for mechanical vitrectomy between January 2017 and December 2017. Demographic and perioperative data were collected, namely ASA physical status, median arterial pressure, heart rate, postoperative opioid consumption, postoperative nausea and vomiting, times of induction, surgery, recovery, and hospital stay and costs considering medication and material needed. Statistical analysis was performed using SPSS v.25, with chi-square, Fisher and Mann-Whitney U tests, according to the type of variables analysed. RESULTS AND DISCUSSION: We included 179 patients submitted for mechanical vitrectomy: 91 (51%) with PB and 88 (49%) under GA. Patients submitted to PB were older (69.0 vs. 64.5 years, p=.006) and presented with higher ASA physical status (p=.001). For haemodynamic outcomes, patients submitted to PB presented with less variation of median arterial pressure (-3.0 vs. -13.5mmHg, p=.000) and with no significant differences in heart rate (-2.0 vs. -3.0 bpm, p=.825). In the postoperative period, the PB group presented with decreased need of postoperative analgesia (0.0 vs. 5.0, p=.026) and a lower incidence of nausea and vomiting (1.0 vs. 12.0, p=.001). Times related to anaesthesia and surgery were better in PB group, with shorter induction time (10.0 vs. 11.0min, p=.000), surgery time (56.5 vs. 62.0min, p=.001), recovery time (10.0 vs. 75.5min, p=.000), and hospital stay (2.0 vs. 3.0 days, p=.000). When analysing costs, PB was less expensive than GA (4.65 vs. 12.09 euros, p=.021) CONCLUSION: PB is a reliable and safe alternative to GA for patients undergoing mechanical vitrectomy, permitting good anaesthesia and akinesia conditions during surgery, better haemodynamic stability, and less postoperative complications, especially in older patients and those with more comorbidities.

Cost Analysis of a Multidisciplinary Vascular Anomaly Clinic.

OBJECTIVE: Multidisciplinary vascular anomaly clinics (VACs) offer important value to pediatric patients with complex vascular anomalies whose care overlaps specialties. These clinics are labor intensive and costly to operate since providers see fewer patients compared to their individual specialty clinic. Our North American tertiary care institution's VAC specialists include a pediatric otolaryngologist, pediatric surgeon, pediatric plastic surgeon, pediatric dermatologist, and interventional radiologist. To assess financial feasibility, we conducted a cost analysis of our VACs comprised of 2 half-day multidisciplinary physician attended clinics (5 specialists at our main campus and 2 specialists at a satellite clinic) and a half-day nurse practitioner clinic. METHOD: Assessment of net revenue based on net collections for clinic, professional, operative, hospital setting, and facility charges generated during 12 consecutive monthly VACs beginning July 1, 2015. Expense calculations included provider and staff salaries, benefits, supply costs, and clinic leasing costs. RESULTS: There were 469 clinic visits, of which 202 were new patient evaluations. Sixty-eight patients underwent 93 procedures under general anesthesia, including procedures performed by our interventional radiologist, most commonly sclerotherapy or embolization (n = 37), surgical interventions including endoscopy (n = 36), or laser procedures (n = 20). Three patients were admitted. Fifty-seven patients received a new diagnosis different from that for which they were referred. Gross revenue was $1 810 525, and net revenue was 42.5%, or $783 152. Expenses totaled $453 415 for a net positive revenue of $329 737. CONCLUSION: When including direct downstream revenue, particularly from operative procedures, our VAC program operates on a net positive margin, making the program financially feasible.

The Prevalence and Factors Associated with Sibling-Recurrent Dental Treatment Under General Anesthesia at an Academic Institution.

Purpose: The purpose of this study was to assess the prevalence of and factors that contribute to sibling-recurrent dental general anesthesia (DGA) at the Department of Pediatric Dentistry, Virginia Commonwealth University, Richmond, Va., USA. Methods: Subjects were recruited from July 25, 2017 to March 15, 2018. The guardian of patients with siblings who attended a university pediatric dental clinic were provided a questionnaire to assess the prevalence and factors associated with recurrent DGA. A provider survey was completed to ensure inclusion/exclusion criteria were met. Results: A total of 40 families with a child presenting for general anesthesia (GA) and who had at least one sibling were included in the study. Of these, 45 percent had sibling-recurrent GA treatment; 20 percent of patients had one sibling; and 25 percent had two or more sibling-recurrent DGA (P<.05). Additionally, 13 percent of the children currently presenting for GA had already been treated under GA, and 15 percent of the siblings previously treated with GA had recurrent caries after GA. Conclusions: Sibling-recurrent general anesthesia is high at Virginia Commonwealth University's Pediatric Dentistry Clinic. This increased prevalence could be due to parental acceptance and positive experiences with DGA. Dental providers should be proactive with prevention of recurrent DGA.

Children centered care: Minimizing the need for anesthesia with a multi-faceted concept for MRI in children aged 4-6.

PURPOSE: To evaluate the need for general anesthesia (GA) in MRI in children aged 4-6 years, using a multi-faceted concept, Children Centered Care (CCC), compared to a standard setup. MATERIALS AND METHODS: In this prospective study of 81 children, we developed and tested a multi-faceted concept, CCC, for MRI in children aged 4-6 without GA, comparing it to a standard setup. The CCC included: 1) an interactive app, 2) a trained pediatric team, 3) a children's lounge with a toy-scanner, and 4) a child-friendly multimedia environment in the MRI room. Patients were included from February-September 2016 and 2017. The use of GA was evaluated, image quality was assessed and a cost-benefit analysis was done. RESULTS: We included 40 children in the control group and 41 in the CCC group. Mean age was 5.8 years and 48 (59%) were males. Neuro and orthopedic imaging accounted for 58 (72%) and 22 (27%), respectively. With the CCC setup 39/41 (95%) completed a diagnostic MRI without GA compared to 17/40 (43%) in the control group (p < 0.001). Image quality was not different between the groups (p = 0.37). The setup proved cost-effective with a payback time of two years in a Danish setting with 250 eligible patients per year. CONCLUSION: With the multi-faceted concept CCC, the use of GA for MRI in children aged 4-6 was markedly reduced to 5%, image quality was maintained and the setup was cost-effective.

Predicting patients requiring discharge to post-acute care facilities following primary total hip replacement: Does anesthesia type play a role?

STUDY OBJECTIVE: We sought to develop a predictive model for discharge to post-acute care facilities in patients undergoing unilateral total hip replacement (THR). Furthermore, we sought to determine if the use of neuraxial anesthesia was an important covariate for the predictive model. DESIGN: Retrospective observational study. SETTING: Preoperative care and operating room at a single institution. PATIENTS: Patients (n = 960) who underwent an elective primary THR between 2014 and 2016. INTERVENTIONS: No intervention was performed. MEASUREMENTS: We collected variables that were known preoperatively including age, sex, body mass index (BMI), preoperative opioid use, functional status based on metabolic equivalents (METS), preoperative anemia, thrombocytopenia, osteoarthritis and contralateral osteoarthritis grade, anesthesia type, comorbidities and surgical approach. We then performed multivariable logistic regression to develop a predictive model. MAIN RESULTS: Female sex, preoperative opioid use, older age, general anesthesia, anemia, hypertension, a psychiatric diagnosis, use of dialysis, metabolic equivalents <4 and obesity are all risk factors for a post-acute facility discharge. The use of general anesthesia compared to neuraxial anesthesia was associated with increased odds (odds ratio 1.98, 95% confidence interval 1.31-3.00, p = 0.001) for post-acute facility discharge. Model performance was assessed using ten-fold cross-validation - the average area under the receiver operating characteristic curve calculated was 0.794. CONCLUSIONS: We developed a predictive model for post-acute care facility discharge following THR. The use of neuraxial anesthesia was associated with decreased odds for post-acute care facility discharge.

Incidence, characteristics, and predictive factors for medication errors in paediatric anaesthesia: a prospective incident monitoring study.

BACKGROUND: Medication errors are not uncommon in hospitalized patients. Paediatric patients may have increased risk for medication errors related to complexity of weight-based dosing calculations or problems with drug preparation and dilution. This study aimed to determine the incidence of medication errors in paediatric anaesthesia in a university paediatric hospital, and to identify their characteristics and potential predictive factors. METHODS: This prospective incident monitoring study was conducted between November 2015 and January 2016 in an exclusively paediatric surgical centre. Children <18 yr undergoing general anaesthesia were consecutively included. For each procedure, an incident form was completed by the attending anaesthetist on an anonymous and voluntary basis. RESULTS: Incident forms were completed in 1400 (73%) of the 1925 general anaesthetics performed during the study period with 37 reporting at least one medication error (2.6%). Drugs most commonly involved in medication errors were opioids and antibiotics. Incorrect dose was the most frequently reported type of error (n=27, 67.5%), with dilution error involved in 7/27 (26%) cases of incorrect dose. Duration of procedure >120 min was the only factor independently associated with medication error [adjusted odds ratio: 4 (95% confidence interval: 2-8); P=0.0001]. CONCLUSIONS: Medication errors are not uncommon in paediatric anaesthesia. Identification of the mechanisms related to medication errors might allow preventive measures that can be assessed in further studies.

Retrospective study of intra-anesthetic predictors of prolonged hospitalization, increased cost of care and mortality for canine patients at a veterinary teaching hospital.

OBJECTIVE: To determine the impact of intraoperative anesthetic variables on the length of hospitalization, cost of care and mortality in dogs. STUDY DESIGN: Retrospective, observational study. ANIMALS: A total of 235 dogs undergoing general anesthesia. METHODS: Medical records of dogs undergoing general anesthesia between 2007 and 2014 at the University of Georgia Veterinary Teaching Hospital were reviewed. Data collected included demographic data, American Society of Anesthesiologists (ASA) physical status, type and duration of anesthesia, hemodynamic variables, temperature, ventilation, fluid therapy and adjunctive drugs administered. Outcome variables were length of hospitalization in the intensive care unit (ICU), hospital charges and survival to discharge. RESULTS: The only factor significantly associated with duration of ICU care was higher ASA status (p<0.0001). Factors associated with increased cost of hospitalization were ICU duration (p<0.0001), anesthesia duration (p<0.0001), hemorrhage amount (p<0.0001), colloid use (p=0.0081), increased age (p=0.0253), increased weight (p = 0.0293) and presence of hypertension (p=0.0179). Overall mortality rate was 5.1%. The only factors negatively associated with survival were the administration of colloids (p<0.0008) and ASA status (p=0.0314). CONCLUSIONS AND CLINICAL RELEVANCE: Several intrinsic patient factors and intraoperative hemodynamic variables were significantly associated with postoperative morbidity and mortality in dogs. These factors might have prognostic value in conjunction with preoperative risk assessment, and patient outcome may be improved by stricter intraoperative control of these variables.

Exploring the potential value of using data on dental extractions under general anaesthesia (DGA) to monitor the impact of dental decay in children.

Aim To explore the value of DGA data as an indicator of the impact and inequalities associated with child dental decay (caries) in Southampton.Design Data from the local DGA provider in Southampton was used to investigate trends in child (17 years and under) DGAs between 2006/7 and 2014/15. Retrospective analysis of anonymised child-level 2013/14 and 2014/15 data from the same service was carried out to identify any inequalities with respect to deprivation, impact on school attendance and cost to the health economy.Results Around 400-500 Southampton children needed a DGA annually within this period. There were year-on-year variations, but no upward or downward trend. The DGA rate was 2.5 to three times higher in the most deprived quintile compared to the least. This translates to an equivalent gap in school absences, which could impact on educational achievement. The cost of these procedures in 2014/15 was around £210,000.Conclusions DGA data have value in highlighting the impact and inequalities associated with dental decay on children and the wider economy. Nationally, they could be used for benchmarking. Locally, these data could be used to target and evaluate health improvement programmes as well as to highlight DGA service changes that would disproportionately affect children from more deprived backgrounds.

MRI Utilization and the Associated Use of Sedation and Anesthesia in a Pediatric ACO.

BACKGROUND AND OBJECTIVES: MRI is commonly used in the pediatric population and often requires sedation or general anesthesia to complete. This study used data from a pediatric accountable care organization (ACO) to investigate trends in MRI utilization and in the requirement for anesthesia to complete MRI examinations. METHODS: The Partners for Kids (PFK) ACO claims database was queried for MRI examination encounters involving patients 0 to 18 years old from 2009 to 2014, with utilization expressed as encounters per 10,000 PFK members-months. Data were limited to 2011 to 2014 to ensure consistent billing of anesthesia services. Encounters were classified according to the presence of procedure codes for anesthesia or sedation. RESULTS: MRI utilization was approximately constant over the study period at 11 to 12 encounters per 10,000 member-months. The need for anesthesia increased from 21% to 28% of encounters over 2011 to 2014. The latter increase was shared across 1- to 6-year-old, 7- to 12-year-old, and 12- to 18-year-old subgroups. In multivariable regression analysis of monthly utilization, increasing need for anesthesia could not be attributed to secular trends in patient demographics or types of examinations ordered. Paid cost data were available for outpatient MRIs, and MRIs with sedation accounted for an increasing share of these costs (from 22% in 2011 to 33% in 2014). CONCLUSION: There was an increasing need for anesthesia services to complete MRI examinations in this pediatric population, resulting in increasing cost of MRI examinations and presenting a challenge to ACO cost containment.

Surgical Approach and Anesthetic Modality for Carpal Tunnel Release: A Nationwide Database Study With Health Care Cost Implications.

Background: Carpal tunnel release (CTR) is commonly performed for carpal tunnel syndrome once conservative treatment has failed. Operative technique and anesthetic modality vary by surgeon preference and patient factors. However, CTR practices and anesthetic trends have, to date, not been described on a nationwide scale in the United States. Methods: The PearlDiver Patient Records Database was used to search Current Procedural Terminology codes for elective CTR from 2007 to 2011. Anesthetic modality (eg, general and regional anesthesia vs local anesthesia) and surgical approach (eg, endoscopic vs open) were recorded for this patient population. Cost analysis, patient demographics, regional variation, and annual changes in CTR surgery were evaluated. Results: We identified 86 687 patients who underwent carpal tunnel surgery during this 5-year time period. In this patient sample, 80.5% of CTR procedures were performed using general or regional anesthesia, compared with 19.5% of procedures performed using local anesthesia; 83.9% of all CTR were performed in an open fashion, and 16.1% were performed using an endoscopic technique. Endoscopic surgery was on average $794 more expensive than open surgery, and general or regional anesthesia was $654 more costly than local anesthesia. Conclusions: In the United States, open CTR under local anesthesia is the most cost-effective way to perform a CTR. However, only a small fraction of elective CTR procedures are performed with this technique, representing a potential area for significant health care cost savings. In addition, regional and age variations exist in procedure and anesthetic type utilized.

Dental Treatment and Expenditures Under General Anesthesia Among Medicaid-Enrolled Children in North Carolina.

PURPOSE: Many studies reporting dental utilization under general anesthesia (GA) are dated. The purpose of this study was to provide contemporaneous data about children receiving dental GA by: (1) determining trends in utilization and associated expenditures; and (2) examining the effects of provider distribution. METHODS: This time series cross-sectional study of Medicaid-eligible children ages zero to eight years old in North Carolina used aggregate Medicaid claims from State Fiscal Years (SFY) 2011 to 2015 to collect demographic and dental treatment information. Descriptive statistics were stratified by age and year to examine trends over time. Panel analysis techniques were used to explore regional effects of provider distribution on dental GA utilization. RESULTS: For SFY 2011 to 2015, the overall dental utilization rate was 517.1 per 1,000 (total enrolled equals 632,941 children/year), and the dental GA utilization rate was 15.8 per 1,000. Total dental expenditures averaged $113 million per year, and dental GA averaged $16.7 million per year. The dental GA proportion of expenditures increased over time (P<.001). Provider distribution did not affect dental GA utilization rate (P=.178) but did increase the number of children receiving dental GA (P<.001). CONCLUSIONS: Utilization and expenditures associated with dental treatment under general anesthesia continue to increase. While this reflects increased access to care, interventions should be examined to provide preventive care earlier in a child's life.

Use of and Access to Deep Sedation and General Anesthesia for Dental Patients: A Survey of Ontario Dentists.

OBJECTIVE: This study aims to assess barriers to the use of deep sedation/general anesthesia (DS/GA) identified by dentists in Ontario. METHODS: An email invitation to a web-based survey was distributed to all licensed dentists and specialists who have provided an email address to the provincial regulator (n = 5507). Descriptive and regression analyses were performed to explore practice and demographic factors associated with the use of DS/GA. RESULTS: The response rate was 18.3%. A quarter (24.8%) of respondents reported inadequate access to DS/GA. Access was poorest in rural communities and greatest in the Greater Toronto Area (GTA). Overall, 74.5% of dentists indicated that they had used DS/GA in the past 12 months. Use was defined as having provided the service or referred a patient in the past 12 months. Non-use was most likely among general dentists, part-time dentists, dentists > 64 years and dentists in urban locations. Wait times and travel distances were reported as longer for medically complex patients. The most common reasons for non-use of DS/GA were a lack of perceived demand and additional costs to patients. For DS/GA users, the greatest barrier was additional costs to patients. CONCLUSION: Access to DS/GA in Ontario is not uniform; it remains a challenge in rural communities and regions outside the GTA, especially in the north. Use is lowest among general dentists and urban dentists despite adequate access, with dentists' perception of need for DS/GA and cost to the patient acting as major barriers. Education for dentists and better insurance coverage for patients may improve access for these patients.

Decreasing Diagnostic Hysteroscopy Performed in the Operating Room: A Quality Improvement Initiative.

OBJECTIVES: At our institution, diagnostic hysteroscopy (DH), often combined with uterine curettage, commonly has been performed in the main OR with the patient under general anaesthesia. Our objective was to create targeted interventions aimed at decreasing the number of DHs performed in the OR by 75% over one year. METHODS: This quality improvement initiative had a quasi-experimental (time-series) design. To obtain baseline numbers of DHs performed each month, we conducted a retrospective chart audit at a university teaching hospital. We implemented the following three groups of interventions: (1) staff education and case review, (2) accessible sonohysterography, and (3) an operative hysteroscopy education program. Procedures were tracked prospectively over a 12-month intervention period and an additional 12-month maintenance period. RESULTS: One hundred eleven DHs were performed at baseline. During the intervention period, 33 DHs were performed, a 70% reduction from baseline. This resulted in related savings of $126 984 and 12.5 surgical days. In the final quarter of the intervention period, there was an 81% reduction in the number of DHs with adequate preoperative evaluation compared with baseline. Twenty DHs were performed in the maintenance period, an 82% reduction from baseline. The absolute number of complications from DH remained constant during the study period. CONCLUSION: Carefully planned and targeted interventions to change the culture at our institution decreased the number of DHs performed in the main OR. These initiatives improved patient care, saved costs, and improved OR utilization. Long-term follow-up showed maintenance of the improvements in the year subsequent to the interventions.

Cost Analysis of Spinal Versus General Anesthesia for Lumbar Diskectomy and Laminectomy Spine Surgery.

BACKGROUND: Lumbar spine surgery can be performed using various anesthetic modalities, most notably general or spinal anesthesia. Because data comparing the cost of these anesthetic modalities in spine surgery are scarce, this study asks whether spinal anesthesia is less costly than general anesthesia. METHODS: A total of 542 patients who underwent elective lumbar diskectomy or laminectomy spine surgery between 2007 and 2011 were retrospectively identified, with 364 having received spinal anesthesia and 178 having received general anesthesia. Mean direct operating cost, indirect cost (general support staff, insurance, taxes, floor space, facility, and administrative costs), and total cost were compared among patients who received general and spinal anesthesia. Linear multiple regression analysis was used to identify the effect of anesthesia type on cost and determine the factors underlying this effect, while controlling for patient and procedure characteristics. RESULTS: When controlling for patient and procedure characteristics, use of spinal anesthesia was associated with a 41.1% lower direct operating cost (-$3629 ± $343, P < 0.001), 36.6% lower indirect cost (-$1603 ± $168, P < 0.001), and 39.6% lower total cost (-$5232 ± $482, P < 0.001) compared with general anesthesia. Shorter hospital stay, shorter duration of anesthesia, shorter duration of operation, and lower estimated blood loss contributed to lower costs for spinal anesthesia, but other factors beyond these were also responsible for lower direct operating and total costs. CONCLUSIONS: When comparing the benefits of spinal and general anesthesia, spinal anesthesia is less costly when used in patients undergoing lumbar diskectomy and laminectomy spine surgery.

Racial and Ethnic Disparities in Mode of Anesthesia for Cesarean Delivery.

BACKGROUND: Racial and ethnic disparities have been identified in the provision of neuraxial labor analgesia. These disparities may exist in other key aspects of obstetric anesthesia care. We sought to determine whether racial/ethnic disparities exist in mode of anesthesia for cesarean delivery (CD). METHODS: Women who underwent CD between 1999 and 2002 at 19 different obstetric centers in the United States were identified from the Maternal-Fetal Medicine Units Network Cesarean Registry. Race/ethnicity was categorized as: Caucasian, African American, Hispanic, and Non-Hispanic Others (NHOs). Mode of anesthesia was classified as neuraxial anesthesia (spinal, epidural, or combined spinal-epidural anesthesia) or general anesthesia. To account for obstetric and non-obstetric covariates that may have influenced mode of anesthesia, multiple logistic regression analyses were performed by using sequential sets of covariates. RESULTS: The study cohort comprised 50,974 women who underwent CD. Rates of general anesthesia among racial/ethnic groups were as follows: 5.2% for Caucasians, 11.3% for African Americans, 5.8% for Hispanics, and 6.6% for NHOs. After adjustment for obstetric and non-obstetric covariates, African Americans had the highest odds of receiving general anesthesia compared with Caucasians (adjusted odds ratio [aOR] = 1.7; 95% confidence interval [CI], 1.5-1.8; P < 0.001). The odds of receiving general anesthesia were also higher among Hispanics (aOR = 1.1; 95% CI, 1.0-1.3; P = 0.02) and NHOs (aOR = 1.2; 95% CI, 1.0-1.4; P = 0.03) compared with Caucasians, respectively. In our sensitivity analysis, we reconstructed the models after excluding women who underwent neuraxial anesthesia before general anesthesia. The adjusted odds of receiving general anesthesia were similar to those in the main analysis: African Americans (aOR = 1.7; 95% CI, 1.5-1.9; P < 0.001); Hispanics (aOR = 1.2; 95% CI, 1.1-1.4; P = 0.006); and NHOs (aOR = 1.2; 95% CI, 1.0-1.5; P = 0.05). CONCLUSIONS: Based on data from the Cesarean Registry, African American women had the highest odds of undergoing general anesthesia for CD compared with Caucasian women. It is uncertain whether this disparity exists in current obstetric practice.

Telemedicine Consultations in Oral and Maxillofacial Surgery: A Follow-Up Study.

PURPOSE: The purpose of this study was to follow up on the previous study in evaluating the efficiency and reliability of telemedicine consultations for preoperative assessment of patients. MATERIALS AND METHODS: A retrospective study of 335 patients over a 6-year period was performed to evaluate success rates of telemedicine consultations in adequately assessing patients for surgical treatment under anesthesia. Success or failure of the telemedicine consultation was measured by the ability to triage patients appropriately for the hospital operating room versus the clinic, to provide an accurate diagnosis and treatment plan, and to provide a sufficient medical and physical assessment for planned anesthesia. Data gathered from the average distance traveled and data from a previous telemedicine study performed by the National Institute of Justice were used to estimate the cost savings of using telemedicine consultations over the 6-year period. RESULTS: Practitioners performing the consultation were successful 92.2% of the time in using the data collected to make a diagnosis and treatment plan. Patients were triaged correctly 99.6% of the time for the clinic or hospital operating room. Most patients (98.0%) were given sufficient medical and physical assessment and were able to undergo surgery with anesthesia as planned at the clinic appointment immediately after telemedicine consultation. Most patients (95.9%) were given an accurate diagnosis and treatment plan. The estimated amount saved by providing consultation by telemedicine and eliminating in-office consultation was substantial at $134,640. CONCLUSION: This study confirms the findings from previous studies that telemedicine consultations are as reliable as those performed by traditional methods.